This article was originally a post in our discussion forums, but it was thought to be a valuable lesson learned and has now been published in the hope it can help others. This article may be updated in time with the most recent findings, so check back soon in case there are any new developments.
Accident in work ... bad makes worse
Today I was witness to the aftermath of an accident in work. A team of us went to do some maintenance and part of the job was lowering a column using a winch. A job we do almost daily. All staff are trained on use of the winches. All winches are tested and tagged.
So what went wrong? Apparently they were winding the column down as they have done on many occasions when a bit of slack in the cable on the winch drum allowed the column to slip slightly. This is not unusual but allows the column to drop an inch or so, but on this occasion the slack managed to allow the cable to slip between off the pulley and jam "down the side". As they were in the process of winding the pole down this caused a bit of slack on the pulley side as the cable was now jammed.
This was an unusual occurrence that had not occurred before. So they were looking for a way to un-jam the cable. I am not sure what happened then but apparently, while they were investigating the jam, the cable slipped dragging the victims hand into the pulley. The full weight of the column was now on his hand and he could not free it. I was actually doing another job when I heard a commotion. I ran to the site and found the situation described above. The other two staff working with the victim were at odds as to what to do to say the least. I first had to release the trapped hand. To do this I had to relieve the pressure on the cable. The only way to achieve this was to manually force the column down. I got the other two workers to assist and we got enough slack for the victim to withdraw his hand. His injuries looked horrendous. One finger had a deep gash on both sides and another had a deep gash on one side. First aid consisted of cleaning the wounds with alcohol free wipes and applying a bandage then I sent him off to casualty with one of the other members of staff who had local knowledge of how to get to the local hospital. I reported the accident to our accident reporting line and the well oiled procedures kicked into place. Within minutes I was contacted by my line manager and the union H&S rep. Tomorrow I have to go to base to file a report and return the winch for testing. The line manager has arranged for photographs to be taken at the scene to aid with the investigation. We were lucky. Though the injuries looked horrendous there was no damage to bones, tendons or nerves. The victim was driven home, though protesting that he was OK to drive, and will probably be off for at least a week. He could easily have lost his fingers. After the victim had gone to hospital I was left with a column jammed half up and half down. The same situation they had before the accident. This required an additional winch to take the tension off the existing cable to allow it to be freed safely. Obviously something went wrong with the safe system of work. Now we have to find out how to stop this happening in future. This is a classic example of an unusual occurrence escalating into injury. In an attempt to put right something that had gone wrong the situation compounded from an incident to an accident.
The Investigation
Things moved pretty fast this morning. I had to go to the depot and fill out a witness report. Both winches, the original one and the one used to un-jam the column, have been taken in for inspection as required by LOLER. Then there was a site meeting attended by myself and another who was present at the time, our line manager, his manager and a senior member of the Health and Safety team during which photographs and measurements were made to assist in the investigation and some concerns highlighted. It was stressed throughout the meeting that there would be no blame attached to anybody and the purpose was to ensure that we were not being told to do something that was dangerous. The victim has been signed off by his doctor for at least a week which makes the accident reportable under RIDDOR.
What went wrong?
Quick update. The investigation is ongoing. Not being part of the H&S team I am not privy to all actions but I have been made aware of a few. Both winches involved have been inspected. The original winch involved has no damage. However, as the winch I used to recover from the situation could not be mounted correctly (there was another winch on the mounting point) it now has to have a new cable fitted, the old cable being kinked where it was fastened around the pole. The main issue raised is that, although the winches are regularly tested by an outside firm, the pulley wheels we use were not. The pulley wheel in use at the time of the accident had a slightly elongated hole which allowed it to tilt on the spindle increasing the chances that the cable would run off and jam.. Initial action is to replace ALL pulley wheels in the field and ensure that they are renewed every time the winches are tested. Another issue raised was a result of the investigation but not relevant to the accident. During the site visit I lowered the pole. The H&S manager noted that as I was winding the cable back onto the winch after securing the pole I allowed the cable to slip between my fingers to keep tension on it. Doing this put me at risk of hand injury should there be any frayed ends on the cable. So I have been informed that in future I must wear gloves and hold the cable by the thimble at the end.
Three weeks on...
The injured member of staff is still off work. I spoke to him yesterday and he is still on painkillers and just getting movement back in his fingers. He will be attending his GP's surgery again this week to ascertain whether he needs more time off and/or physiotherapy.
All staff involved in using these winches are to attend retraining at the manufacturers premises later this month. This will entail a 400 mile round trip on top of the training effectively taking all staff out of action for a day as well as travelling costs.
Phil
